Beruflich Dokumente
Kultur Dokumente
HYPERTENSION IN PREGNANCY
June, 2006
Inside
Summary_______________________ 2
The TESS Ad Hoc Advisory
Working Group _________________ 2
1. Introduction _________________ 3
2. Relevance __________________3-4
2.1 Adverse Maternal Outcome
2.2 Adverse Neonatal Outcome
3. Risk Factors__________________ 4
4. Classification _______________4-5
4.1 Measurement of Blood Pressure
4.2 Current Canadian
Hypertension Society (CHS)
Definitions
5. Pathophysiology_____________ 6-7
5.1 Placental Involvement
5.2 HELLP Syndrome, Liver and
Peripheral Vascular
Involvement
5.3 Kidney Involvement
5.4 Central Nervous System
Involvement
5.5 Cardiovascular: Left
Ventricular Failure
5.6 Pulmonary Oedema
British Columbia
Reproductive Care
Program
F5 4500 Oak Street
Vancouver, BC
Canada V6H 3N1
Tel: 604.875.3737
Web: www.rcp.gov.bc.ca
While every attempt has been
made to ensure that the information contained herein is
clinically accurate and current,
the BCRCP acknowledges that
many issues remain controversial, and therefore may be subject to practice interpretation.
9. Management of Severe
Pre-Eclampsia_______________9-10
9.1 For Pharmacological
Management of Severe
Hypertension see Section 10.2
9.2 General Measures
9.3 Basic Investigations
9.4 Maternal assessment / Monitoring
9.5 Fetal Assessment
9.6 Thromboprophylaxis
Steroids
Mode of Delivery
Anaesthsia and Fluids
Indications for Central Venous
Pressure (CVP) Monitoring
13. Postpartum__________________ 15
13.1 Fuid Management
13.2 Analgesia
BCRCP, 2006
References _____________________ 16
Appendix A ____________________18
Summary
This guideline reflects both the variable presentation
and the systemic nature of gestational hypertension
with proteinuria and/or adverse conditions
(referred to as pre-eclampsia in this guideline)1 and
the other hypertensive disorders of pregnancy.
Recommendations for the comprehensive evaluation
and management of organ dysfunction associated
with pre-eclampsia are included.
The main points in the guideline are:
n Pre-eclampsia is a systemic disorder that may
affect many organ systems
n For pre-eclampsia remote from term (<34
weeks), expectant management is associated
with improved perinatal outcomes. Expectant
management requires obsessive surveillance to
mitigate maternal risks and is a package.
n Initial assessment and ongoing surveillance of
women with a hypertensive disorder of pregnancy
should include assessment of all vulnerable
maternal organs as well as the fetus. A set of
standardized orders is included in Appendix A.
n Initiate antihypertensive drug treatment:
Immediately (in the absence of pre-pregnancy
renal disease or diabetes)
o sBP >160 mmHg or dBP >110 mmHg
o sBP 140-159 mmHg and/or dBP 85-109
mmHg, based on practitioner preference,
training, and experience
In the presence of pre-pregnancy renal disease or
diabetes
sBP >140 mmHg or dBP >90 mmHg
n Recommended treatment of non-severe
hypertension in pregnancy
Treatment goal: dBP 80-105 mmHg (depending
on practitioner preference)
o First choice agent: Methyldopa (Aldomet)
o Second choice agents: Labetalol
(Trandate); Nifedipine (Adalat PA or XL)
o Special indications (renal or cardiac
diseases): diuretics
Drugs to avoid: angiotensin-converting enzyme
inhibitors; angiotensin II receptor antagonists;
atenolol
n Acute management of severe hypertension
Reduce dBP by 10 mmHg in the first instance and
maintain the blood pressure at or below that
level.
o First choice agent: Nifedipine
o Second choice agent: Labetalol
n Anticonvulsant therapy
Prophylaxis: MgSO4 (4g IV stat, then 1g/hr)
Management of eclampsia: MgSO4 (4g IV stat,
then 1g/hr)
Management of recurrent seizures: MgSO4 (2g IV
stat, then increase to 1.5g/hr)
n Fluids: total intake should not exceed 80 ml/hr;
tolerate urine outputs as low as 10 ml/hr.
1. INTRODUCTION
This guideline has been developed to reflect both
the variable presentation and the systemic nature of
pre-eclampsia1 and the other hypertensive disorders of
pregnancy.2-4 The recommendations are derived from
the pattern of investigation used in other centres of
excellence, in response to international guidelines,5-8
in response to current practice across Canada,9,10 and
preliminary evidence that it may be possible to predict
those women most at risk of doing poorly.11 It must be
remembered that up to 40% of women who develop
eclampsia (seizures) will not have had both hypertension and proteinuria in the week preceding their first
seizure.12 Therefore, to proffer the greatest safety to
women, we should consider (and continue to consider)
pre-eclampsia in all women presenting with either
hypertension or proteinuria in pregnancy, as well as
those women who present with the symptoms of preeclampsia in the absence of both hypertension and
proteinuria.
Pre-eclampsia remains the most common cause of
maternal mortality in North America, and it is apparent that the surveillance of women with suspected or
confirmed pre-eclampsia is variable between practitioners.9,10 In an era of effective blood pressure control,13,14 it is end organ failure (especially hepatic and
respiratory complications) that most commonly causes
women to die from pre-eclampsia.4,15 This guideline
includes recommendations for the comprehensive
evaluation of organ dysfunction.
The pattern of investigations presented in this
guideline aims to standardize the approach to care
within British Columbia, with consideration that
the choice of Mondays to Thursdays provides the
best timing for delivery of infants (away from Friday
evenings and weekends). Of course, some or all of
these investigations may be performed at other
additional times, at the discretion of the attending
physician.
Since the introduction of the pre-printed physician
orders (Appendix A) in September 2003, the incidence
of an internationally-determined combined adverse
maternal outcome has fallen from 5.1% to 0.8%
(p<0.05) in those women admitted to BC Womens
Hospital and Health Centre with pre-eclampsia for
whom these orders were used.16
2. RELEVANCE
The following data is from the British Columbia
Perinatal Database Registry for fiscal years 2001/02,
2002/03, and 2003/04. During this three-year period,
there were a total of 119,387 pregnancies (singleton
and multiples) of which 6,691 (5.6%) were complicated
by hypertension, and 112,696 were non-hypertensive
pregnancies. For this dataset, hypertension is defined
as any of the following conditions (classified by ICD 10
codes):
3. RISK FACTORS
Family history
Primigravida
Multiple gestation
4. CLASSIFICATION
4.1 MEASUREMENT OF BLOOD PRESSURE
Blood pressure should be measured:
With the patient resting at 45 supported and
with the upper arm at the level of the heart
1.
Essential
2. Secondary
B. Gestational hypertension
1.
Without proteinuria
Definition
Diastolic hypertension that predates pregnancy or is diagnosed
before 20 weeks gestation. In most cases hypertension persists
> 42 days postpartum. It may be associated with proteinuria.
Primary.
Secondary to such conditions as renal disease, phaeochromocytoma
and Cushing syndrome.
Diastolic hypertension develops after 20 weeks gestation. In most
cases it resolves < 42 days postpartum.
Corresponds to previous terminology such as pregnancy induced
hypertension and non-proteinuric hypertension. Protein excretion
in 24-hour urine collection is < 0.3 g/d.
2. With proteinuria
C. Pre-existing hypertension +
superimposed gestational
hypertension with proteinuria
D. Unclassifiable antenatally
5. PATHOPHYSIOLOGY
Frontal headaches
Occipital headaches
Hemiplegia
Visual disturbances
Cardiomyopathy of pre-eclampsia
No adverse features
Liver enzymes
7. INDICATIONS TO CONSIDER
HOSPITALIZATION
Fetal assessment
i. Deepest amniotic fluid pocket >2 cm on
ultrasound.
ii. Non-stress test without decelerations at
gestational ages remote from term.
iii. End diastolic flow present on umbilical artery
Doppler; at gestational ages <34 weeks,
absent end diastolic flow does not necessarily
mandate delivery, but certainly does
mandate very close surveillance. Reversed
end diastolic flow on umbilical artery
Doppler is an indication for delivery.
frontal headache
visual disturbance
persistent epigastric or right upper
quadrant pain
chest pain
shortness of breath
Maternal signs:
Maternal labs:
platelets <100 x 109/L
Bed rest
Weight gain
Proteinuria levels
Fetal movement
General symptoms
8. SEVERE PRE-ECLAMPSIA
8.1 DEFINITIONS
Severe pre-eclampsia (generally synonymous with
gestational hypertension with/without proteinuria
Fetal Assessment
intrauterine growth restriction
oligohydramnios
absent or reversed end diastolic flow on
umbilical artery Doppler
8.1.3 Eclampsia
In clinical practice there are no reliable clinical
markers to predict eclampsia (seizures). The
following are thought to predict the onset of
eclampsia. However, even when these symptoms
are present, in most instances eclampsia does
not develop:
Severe headaches (especially occipital
headaches)
Brisk reflexes >3+ (3+ is hyperactive
without clonus, 4+ is hyperactive with
Visual disturbances
9. MANAGEMENT OF SEVERE
PRE-ECLAMPSIA
9.1 FOR PHARMACOLOGICAL MANAGEMENT
OF SEVERE HYPERTENSION,
SEE SECTION 10.2
FOR PROPHYLAXIS AND TREATMENT OF
ECLAMPSIA, SEE SECTION 11
9.6 THROMBOPROPHYLAXIS
10
A.2 Labetalol
If the woman can tolerate oral therapy, dosing can be done immediately before venous
access and so can achieve as quick a result
as an initial intravenous dose. Initially, 200
mg can be given orally. This should lead to
a reduction in blood pressure in 30 - 60 min,
and peak at 2 - 3 hr. A second oral dose can
be given if needed.
There has been some concern over interaction between magnesium sulphate and
nifedipine; however, the risk is <1%. 26
B. Alternative:
Hydralazine
11
C. Alternatives:
Nifedipine (Adalat PA)
Dosage: Adalat PA: Initiate at 10 mg p.o.
twice daily. Usual maintenance
dose is 10 - 20 mg p.o., b.i.d.
Adalat XL: Initiate at 30 mg daily.
Usual maintenance dose is 30-60
mg given once daily or in two
doses (e.g., 30 mg b.i.d.).
E. Drugs to Avoid
A. Treatment Goal
dBP 80 - 110 mmHg (depending on
practitioner preference)
12
Diuretics
Atenolol
C. Clinical assessment
The medical staff are responsible for the
assessment of the patient and the decision
to continue the infusion. The decision for
continuing the infusion should be made q4h.
The following observations should be
performed:
i) continuous pulse oximetry
ii) hourly urine output
E. Side effects
13
12.1 STEROIDS
14
OR
B. If total input is less than 750 ml in excess of
output in the last 24 hours (or since starting
the regime) then an infusion of 250 ml of
pentaspan over 20 minutes should be given.
The urine output should then be watched
until the end of the next 4-hour block. If
the urine output is still low then 20 mg of
IV furosemide should be given. If a diuresis
in excess of 200 ml occurs in the next hour
the fluid should be replaced with 250 ml of
pentaspan in addition to baseline fluids.
13. POSTPARTUM
High risk women should not be placed onto
low risk discharge pathways. Women should
only be discharged when there is a clear trend
towards improvement in clinical and laboratory
assessments, when there is an ability to provide
adequate outpatient surveillance, and when
follow-up can be arranged within a week for
clinical and blood pressure assessment. It is
reasonable to discharge women with BP
< 160/100 mmHg for at least 24 hours.
The community health nurse should visit on the
1st or 2nd day after discharge, and the woman
should visit her physician within 1 week of
discharge.
13.2 ANALGESIA
Women with pre-eclampsia have vulnerable renal
function. Therefore, non-steroidal anti-inflammatory
agents should be avoided in women whose urine
output is <40 ml/hr.
15
Pulmonary oedema
Breastfeeding at discharge
Maternal mortality
16.2 NEWBORN
REFERENCES
1.
2.
4.
3.
5.
6.
7.
16
9.
17
Appendix A
18
19
20